1. Enhanced Early Outcomes with the Anterior Supine Intermuscular Approach in Primary Total Hip Arthroplasty by Keith R. Berend, Adolph V. Lombardi, Brian E. Seng, and Joanne B. Adams J Bone Joint Surg Am Volume 91(Supplement 6):107-120 November 1, 2009 ©2009 by The Journal of Bone and Joint Surgery, Inc.

2. The standard direct lateral approach to the hip previously described by Frndak et al.21 is performed with the patient in the lateral decubitus position. Keith R. Berend et al. J Bone Joint Surg Am 2009;91:107- 120 ©2009 by The Journal of Bone and Joint Surgery, Inc.

3. The less invasive direct lateral approach is performed with the patient in the lateral decubitus position. Keith R. Berend et al. J Bone Joint Surg Am 2009;91:107- 120 ©2009 by The Journal of Bone and Joint Surgery, Inc.

4. For the anterior supine intermuscular approach, the anterior superior iliac spine is identified and a reference line is drawn to the center of the patella. Keith R. Berend et al. J Bone Joint Surg Am 2009;91:107- 120 ©2009 by The Journal of Bone and Joint Surgery, Inc.

5. The patient is positioned supine with the pubic symphysis at the table break. Keith R. Berend et al. J Bone Joint Surg Am 2009;91:107- 120 ©2009 by The Journal of Bone and Joint Surgery, Inc.

6. An 8 to 10-cm incision is used, with the proximal end placed approximately two fingerbreadths distal and two fingerbreadths lateral to the anterior superior iliac spine. Keith R. Berend et al. J Bone Joint Surg Am 2009;91:107- 120 ©2009 by The Journal of Bone and Joint Surgery, Inc.

7. The correct position of the planned incision is confirmed with fluoroscopy. Keith R. Berend et al. J Bone Joint Surg Am 2009;91:107- 120 ©2009 by The Journal of Bone and Joint Surgery, Inc.

8. The deep muscle fascia of the tensor fasciae latae is split, exposing the lateral circumflex vessels, which will be ligated, cauterized, and transected. Keith R. Berend et al. J Bone Joint Surg Am 2009;91:107- 120 ©2009 by The Journal of Bone and Joint Surgery, Inc.

9. A subcapital resection and final neck resection are performed to create a “napkin ring” slice of femoral neck. Keith R. Berend et al. J Bone Joint Surg Am 2009;91:107- 120 ©2009 by The Journal of Bone and Joint Surgery, Inc.

10. The acetabulum is exposed with a sharp retractor placed superiorly, a double-pronged posterior retractor placed on the ischium, and if necessary an anterior retractor. Keith R. Berend et al. J Bone Joint Surg Am 2009;91:107- 120 ©2009 by The Journal of Bone and Joint Surgery, Inc.

11. Sequential reaming of the acetabulum is performed with use of fluoroscopic guidance as necessary. Keith R. Berend et al. J Bone Joint Surg Am 2009;91:107- 120 ©2009 by The Journal of Bone and Joint Surgery, Inc.

12. For preparation of the femur, the anesthesiologist jackknifes the table by dropping its foot and placing the bed into a steep Trendelenburg position. Keith R. Berend et al. J Bone Joint Surg Am 2009;91:107- 120 ©2009 by The Journal of Bone and Joint Surgery, Inc.

13. The surgeon can directly assess lower-limb length with the patient in the supine position by comparing the medial malleoli and confirming this assessment with fluoroscopy. Keith R. Berend et al. J Bone Joint Surg Am 2009;91:107- 120 ©2009 by The Journal of Bone and Joint Surgery, Inc.

14. After attainment of satisfactory stability and optimization of limb length, the hip is dislocated and the final implant (in this case, a shortened, tapered, wedge-shaped, titanium, porous plasma spray-coated stem) is inserted. Keith R. Berend et al. J Bone Joint Surg Am 2009;91:107- 120 ©2009 by The Journal of Bone and Joint Surgery, Inc.

15. A comparison of the perioperative factors of operative (OR) time, estimated blood loss, and rate of patients requiring blood transfusion between the anterior supine intermuscular (ASI) and less invasive direct lateral (LIDL) approaches. Keith R. Berend et al. J Bone Joint Surg Am 2009;91:107- 120 ©2009 by The Journal of Bone and Joint Surgery, Inc.

16. A comparison of discharge factors (length of acute hospital stay and rate of patients discharged directly to home) between the anterior supine intermuscular (ASI) and less invasive direct lateral (LIDL) approaches. Keith R. Berend et al. J Bone Joint Surg Am 2009;91:107- 120 ©2009 by The Journal of Bone and Joint Surgery, Inc.

17. A comparison of the preoperative and six-week follow-up Harris hip scores between the anterior supine intermuscular (ASI) and less invasive direct lateral (LIDL) approaches. Keith R. Berend et al. J Bone Joint Surg Am 2009;91:107- 120 ©2009 by The Journal of Bone and Joint Surgery, Inc.

18. A comparison of the preoperative and six-week follow-up patient-reported scores on the lower- extremity activity scale between the anterior supine intermuscular (ASI) and less invasive direct lateral (LIDL) approaches. Keith R. Berend et al. J Bone Joint Surg Am 2009;91:107- 120 ©2009 by The Journal of Bone and Joint Surgery, Inc.

19. Preoperative radiograph of the pelvis, demonstrating advanced osteoarthritis in a forty-eight- year-old man who presented with severe pain and loss of function of both hips. Keith R. Berend et al. J Bone Joint Surg Am 2009;91:107- 120 ©2009 by The Journal of Bone and Joint Surgery, Inc.

20. At six weeks after treatment with bilateral total hip arthroplasty performed through the anterior supine intermuscular approach, radiographs demonstrated well-fixed components in satisfactory position and alignment. Keith R. Berend et al. J Bone Joint Surg Am 2009;91:107- 120 ©2009 by The Journal of Bone and Joint Surgery, Inc.